<?php echo $this->Html->css('web/org_subscription.css'); ?>

<div class="bg-gradient clearfix">
    <div class="text-center wrapper">
        <h2>Billing Information</h2>
        <p>Please review the information provided below and complete your registration</p>
    </div>


    <div class="container">

        <div class="row">

            <form method='post' class='form form-horizontal' action='<?php echo $this->Html->url(array('action' => 'register_payments')); ?>'>

                <section class="panel">
                    <div class="panel-body">
                        <div class='form-group'>
                            <label class='col-lg-2 control-label'>Name On Card:</label>
                            <div class='col-lg-10 controls'>
                                <input type='text' class='form-control input-s col-md-3 m-r' placeholder='First Name' name='data[Billing][first_name]' required />
                                <input type='text' class='form-control input-s col-md-3' placeholder='Last Name' name='data[Billing][last_name]' required />
                            </div>
                        </div>

                        <div class='form-group'>
                            <label class='col-lg-2 control-label'>Card Type:</label>
                            <div class='col-lg-10 controls'>
                                <select class='form-control input-s-sm' name='data[Billing][card_type]' required>
                                    <option value=''>Select</option>
                                    <option value='visa'>Visa</option>
                                    <option value='mastercard'>Master Card</option>
                                </select>
                            </div>
                        </div>

                        <div class='form-group'>
                            <label class='col-lg-2 control-label'>Card Number</label>
                            <div class='col-lg-10 controls'>
                                <input type='text' class='form-control input-s' name='data[Billing][card_number]' required />
                            </div>
                        </div>

                        <div class='form-group'>
                            <label class='col-lg-2 control-label'>Security Code</label>
                            <div class='col-lg-10 controls'>
                                <input type='text' class='form-control input-s' name='data[Billing][card_security_code]' required maxlength="4" />
                            </div>
                        </div>

                        <div class='form-group'>
                            <label class='col-lg-2 control-label'>Expiry Date:</label>
                            <div class='col-lg-10 controls'>
                                <select name='data[Billing][expiry_month]' class='form-control input-s-sm col-md-3 m-r' required>
                                    <option value=''>--</option>
                                    <option value='01'>01</option>
                                    <option value='02'>02</option>
                                    <option value='03'>03</option>
                                    <option value='04'>04</option>
                                    <option value='05'>05</option>
                                    <option value='06'>06</option>
                                    <option value='07'>07</option>
                                    <option value='08'>08</option>
                                    <option value='09'>09</option>
                                    <option value='10'>10</option>
                                    <option value='11'>11</option>
                                    <option value='12'>12</option>
                                </select>
                                <select name='data[Billing][expiry_year]' class='form-control input-s-sm col-md-3' required>
                                    <option value=''>--</option>
                                    <?php for ($y = date('Y'); $y < intval(date('Y')) + 10; $y++) { ?>
                                        <option value='<?php echo $y; ?>'><?php echo $y; ?></option>
                                    <?php } ?>
                                </select>
                            </div>
                        </div>
                    </div>

                    <div class='panel-footer text-right bg-light lter'>
                        <a type='button' class='btn btn-default' href='<?php echo $this->Html->url(array('action' => 'register_info')); ?>'><i class='fa fa-backward'></i> Back</a>
                        <button type="submit" class="btn btn-success"><i class='fa fa-forward'></i> Continue</button>
                        <a class="btn btn-cancel btn-danger" href='<?php echo $this->Html->url(array('action' => 'register_cancel')); ?>' >Cancel</a>
                    </div>
                </section>
            </form>
        </div>
    </div>
</div>